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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393610469
Report Date: 05/17/2023
Date Signed: 05/17/2023 11:16:02 AM

Document Has Been Signed on 05/17/2023 11:16 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:CAMARILLO, IDALIAFACILITY NUMBER:
393610469
ADMINISTRATOR:CAMARILLO, IDALIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 922-4993
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
05/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Syana Basilio.TIME COMPLETED:
11:30 AM
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On 05/17/23, Licensing Program Analyst(LPA), Elvira SIerra met with Licensee’s Assistants, Syana Basilio. and Carolyn Boyd for the purpose of conducting a case management visit in order to amend last Case Management report dated May 3rd, 2023. During this visit LPA provided staff with the amended Case Management report. LPA cleared deficiencies cited on 05/03/23. Present in the facility were 2 staff caring for 8 children

LPA received a copy of the incident written report occurred on 06/09/17 and also a statement for proof of correction for deficiency regarding Personal Rights of the children cited on 05/03/23 on today’s visit. LPA also reviewed children’s records and observed the Acknowledgement of Receipt of Licensing Reports (LIC 9224) form signed by parents.

Exit interview conducted and this report and Appeal of Rights were provided t licensee’s Assistant, Carolyn Boyd. Notice of Site Visit was posted.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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